HospitalInspections.org

Based on observation and staff interview, the facility failed to provide call lights in the emergency room to meet the needs of patients in a safe manner.


Findings include:


Observation on 04/18/16 at 10:00 a.m. revealed the facility had no call lights in the two (2) emergency room bays for patient use. No call light system was observed in the nursing station.

During an interview on 4/18/16 at 10:15 a.m. the Director of Nurses stated, "The hospital has not had call lights in the emergency room for years."

There was no system in place for patients/family to notify staff in case of an emergency in one of the emergency room bays.

Based on observation, staff interview, and policy review, the facility failed keep emergency supplies/equipment in date for staff use in treating emergency cases in life-saving procedures.


Findings Include:


Observation on 04/18/16 at 10:30 a.m. revealed three (3) sets of Quick Combo pads which had expired on 2/28/16 and two (2) CO2 detectors which had expired August 2014.


During an interview on 04/18/16 at 10:40 a.m. the Director of Nurses stated, "I was unaware that the Quick Combo pads and CO2 detectors have expired, but I will make sure they are replaced."


Review of the facility's "Crash Carts-Emergency Department" policy, dated 10/12/15, revealed: "...Policy: Crash carts will be checked daily by each shift... Emergency Department Supervisor will check each crash cart monthly for outdated supplies, correct stock, and functioning of laryngoscope handles and blades."

Based on observation and staff interview, the facility failed to ensure the premises are clean and orderly.

Findings Include:
On 04/18/16 at 10:30 a.m. observation revealed that the store room where general waste is taken was not straight and clean. Mop heads were piled up, garbage cans were open with no tops, and the paper towel dispenser was dirty. At 10:35 a.m. the Administrator stated that he would get it cleaned up. Observation in the linen room at 10:40 a.m. revealed linens were piled up to the ceiling. The central supply room had old equipment and old paraphernalia stacked up on shelving to the ceiling. The floor had boxes and multiple other pieces of equipment in the middle of it. The Administrator stated at that time that these rooms would be cleaned up by the next day, 04/19/16.

A policy was requested regarding storage at 4:10 p.m. on 04/18/16, but was not presented during survey.

At exit conference on 04/19/16 at 12:15 p.m. these findings were discussed. No further documentation was presented.

Based on medical record review, staff interview, policy review, and job description review, the facility failed to ensure nursing care plans for five (5) of 21 patient's reviewed were kept current, reviewed on an ongoing basis and revised as needed. Patient #11, #12, #13, #20 and #21.


Findings Include:

Record review for Patient #11 revealed an admission date of 4/04/2016. There was no documented evidence the patient's nursing care plan had been updated or revised since admission.


Record review for Patient #12 revealed an admission date of 4/15/2016. There was no documented evidence the patient's nursing care plan had been updated or revised since admission.


Record review for Patient #13 revealed an admission date of 4/18/2016. There was no documented evidence the patient's nursing care plan had been updated or revised since admission.


Record review for Patient #20 revealed an admission date of 4/04/2016. There was no documented evidence the patient's nursing care plan had been updated or revised since admission.

Record review for Patient #21 revealed an admission date of 3/30/2016. There was no documented evidence the patient's nursing care plan had been updated or revised since admission.


During an interview on 04/18/16 at 2:30 p.m. the Registered Nurse (RN) stated, "When a patient is admitted we pick one of the patient diagnoses and the computer generates a care plan. Care plans are completed on admission and discharge."


Review of the facility's "Patient Care Plan" policy, dated 11/04/08, revealed: "Policy: Care, treatment, and services are planned to ensure that they are appropriate to the patient's needs... Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable.
Procedure: ...The planning for care, treatment and services will include... Regularly reviewing and revising the plan of care, treatment and services... Monitoring the effectiveness of the care planning and the provision of care, treatment and services. The plan of care will be individualized to the needs of the patient. The plan of care will be continually evaluated... The plan of care shall address the learning needs of the patient and/or family. The plan of care shall be updated regularly, with revisions reflecting the reassessment of needs of the patient..."

Review of the facility's "Registered Nurse" job description, revised August 2015, revealed: "A Registered Nurse is responsible for assessing patient health problems and needs, develop and implement nursing care plans, and maintain medical records..."

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure five (5) of 21 patient records reviewed (Patient #5, #6, #7, #8 and #11) are complete, accurately documented, contains a general consent for treatment, contains patient rights documentation and entries contain a documented date, time and/or signature.

Findings Include:


Review of the medical record for Patient #5 revealed no documented evidence of a swing bed "Consent for Treatment and Financial Agreement" or "An Important Message From Medicare About Your Rights" filed in the medical record.

Review of the medical record for Patient #6 revealed the swing bed "Consent For Treatment And Financial Agreement", "Notice of Privacy Practices", and "An Important Message From Medicare About Your Rights" contained no documented evidence of the patient signature. The "Swing Bed Report Progress Note" for Dietary contained no documented evidence of the medical record entry date, time or discipline signature.

Review of the medical record for Patient #7 revealed the "Consent For Treatment And Financial Agreement", "Notice of Privacy Practices" , "Code Classifications", "An Important Message From Medicare About Your Rights" and the "Swing Bed Report Progress Notes for Dietary" contained no documented evidence of the medical record entry date, time or discipline signature.

Review of the medical record for Patient #8 revealed the "Consent For Treatment And Financial" contained no documented evidence of the patient and/or patient representative signature and "An Important Message From Medicare About Your Rights" contained no documented evidence of the medical record entry date, time or patient signature.

Review of the medical record for Patient #11 revealed no documented evidence of a swing bed "Consent For Treatment and Financial Agreement" or "An Important Message From Medicare About Your Rights" filed in the medical record.

During an interview on 04/18/16 at 11:45 a.m., the Medical Record Director confirmed the general consent for treatment and patient rights documentation is part of the medical record.

During an interview on 04/18/16 at 3:35 p.m., RN #1 confirmed Patient #5's medical record contained no documented evidence of a " Consent For Treatment And Financial Agreement" or "An Important Message From Medicare About Your Rights". She stated, "The forms were not given to the patient to sign."


During an interview on 04/19/16 at 10:35 a.m., the Medical Record Director confirmed the "Medical Record Guideline for Physicians", reference #3105, is the facility policy and all disciplines are required to date, time and sign any entry entered into the medical record.


Review of the facility's "Medical Record Guideline for Physicians", reference #3105, revealed: "Policy: The quality of the medical record depends in part on the timeliness, meaningfulness, authentication...of the information it contains. Procedure: General Outlines: All entries must be dated and authenticated ...".


During an interview on 04/19/16 at 11:33 a.m., the Medical Record Director stated, "Each hospital admission should have a signed consent for treatment form."

During an interview on 04/19/16 at 11:36 a.m., the Medical Record Director stated, "(Patient #11) did not have a signed swing bed consent for treatment."

Review of the facility's "Consent" policy, date originated: 01/26/16, revealed: "Purpose: ...This policy ensures that the patient or his or her authorized representative understands and agrees to treatment ...Policy: ...Consent must be obtained from the patient or the parent if the patient is under 18 ...".

Review of the facility's "Informed Consent" policy, revision date 09/18/08, revealed: "Purpose: The purpose of this policy is to establish a process that ensures our patients have the opportunity of exercising their right to participate in decisions process regarding their care, treatment and services. Policy: ...Consent to treat patients can be delineated into ...categories, general consent that grants the hospital permission to treat a patient ...General Consent: All patients or their authorized representative presenting to facility for care treatment and services are required to sign consent or an agreement for treatment. This agreement is presented to the patient/representative upon the patient's arrival to the facility, and covers five different components. These are: Consent to be Treated - whereby the patient gives consent to the physician/nurse practitioner to evaluate and treat the patient; Release of information - Describes the circumstances, the purpose and to whom patient health information may be released; Financial Agreement - The understanding that the patient/representative agrees on the patient ' s obligation to pay for services rendered; Medicare Assignment of Benefits - If applicable, to grant their permissions for facility to submit to Medicare health information to satisfy a claim for payment; Assignment of Benefits - Authorization for payment to be made directly from the insurance company to facility to cover the financial obligation from the patient ...".


Review of the facility's "Advance Directives" policy, revision date 09/29/08, revealed: "...Procedure: ...(Emergency Department) ED/Admission Clerk will document in the medical records whether the patient has completed an advanced directive ...In the event the patient bypasses the routine admission process ...the responsibility to inquire about advanced directive and provide necessary information ...will rest with the nursing staff. The ED/Admitting Clerk will notify the nursing unit of the need for advance directive follow-up ...".